FOR INTERMEDIARY TO ADMINISTER ONLINE ON BEHALF OF EMPLOYER
1. Employer Number/s:
2. Employer Name/s:
that this authorisation shall remain in force until notice in
, terminating the
authorisation is received by
Sovereign Health, provided that any such notice shall not
affect the completion by
MMSA of any transactions or administration already
initiated pursuant to
this authorisation prior to termination.
4. Agree that the appointment of is
at my/our sole risk
5. Acknowledge that MMSA accepts no liability for any
(whether indirect, special or
consequential) or expense of anynature whatsoever
which may be suffered by me/us
arising out of or in connection with this authority,
in particular, but without
limitation, as a result of incorrect instructions given by
that I/we have read and understood the contents of this
application form and agree to be bound by the terms and
conditions contained herein.
Please send a certified copy of your ID with this form.